Application to become a provider

Full Name of Practicing Doctor

Licence Number

Phone

Are You a Member of the BCDO

Are You in Good Standing with the College

Clinic Name

Are you the Owner of the Clinic

Clinic Address

Clinic Phone

Clinic Email

Do you see Patients Under the Age of 18

If Yes How Many do you See Weekly

Do You Dilate Children During an Eye Exam

Why or Why Not

Do You Engage in Vision Rehabilitation in your Optometry Practice

Do You Have Additional Training

Do you Practise Evidence Based or Behavioural / Developmental Optometry

Please Explain Further

Why are You Interested in Being a Provider for WE SEE BC Foundation